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0 ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 UNDERGROUND STORAGE TANK RETROFIT VERIFICATION WITH INSPECTOR ALREADY ONSITE* s _ —:._aM RAW Facility _ �.._ _ FacihInformatio w... -_ Facility �t Name: Contractor Address: Name: Facility I ❑ 89 piping sump Title: Address: Contact: CA License�� ❑ 91 fill sump ❑ 91 piping sump 4 ni__ �, �,`�.�� `�: '� :Contractor• Information x ' _ f��=� , . . `�': ; ..� �-�,`�� Contractor �t Contractor fy Name: 87 fill sumpsv ❑ 89 piping sump ❑ 89 fill sump Address: (.'r CA License�� ❑ 91 fill sump ❑ 91 piping sump Class: Contractor �� ❑ diesel fill sump Number: ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 Phone #: ❑ dispenser 3/4 Insurer: ❑ dispenser 7/8 �� ❑ dispenser 7/8 Workers' �, , comp. #: ICC Tech: ❑ Leak detector replacement ❑ Leak detector replacement Exp. Date: S Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ICC Installer: NO, ❑ Spill container replacement (not direct bury) ❑ Spill container replacement (not direct bury) Exp. Date: Manufacturer n _ _ 4, 'J14414 ❑ 89 -octane UST Exp. Date: 7 � Training: ❑ diesel UST JI ❑ diesel UST ❑ other: Indicate below type of work to be performed. Check all that apply. El replacement replace �t Model: ❑ 87 piping sump ❑ 87 fill sump Model: ❑ 87 piping sump 87 fill sumpsv ❑ 89 piping sump ❑ 89 fill sump ❑ 89 piping sump ❑ 89 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ 91 piping sump ❑ 91 fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ diesel piping sump ❑ diesel fill sump ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 1/2 ❑ dispenser 3/4 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ dispenser 5/6 ❑ dispenser 7/8 ❑ other: ❑ other: ❑ Leak detector replacement ❑ Leak detector replacement Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Spill container replacement (not direct bury) ❑ Spill container replacement (not direct bury) Model: Model: ❑ 87 -octane UST ❑ 89 -octane UST ❑ 87 -octane UST ❑ 89 -octane UST ❑ 91 -octane UST ❑ diesel UST ❑ 91 -octane UST ❑ diesel UST ❑ other: ❑ other: ❑ Bravo float and chain replacement ❑ Automatic tank gauge (ATG) replacement Dispenser: Grade: Model: Dispenser: Grade: ❑ 87 -octane UST ❑ 89 -octane UST Dispenser: Grade: ❑ 91 -octane UST ❑ diesel UST Dispenser: Grade: ❑ other: *This applies only if contractor has all required certifications. PR#: V� ) I PE: %ZI/ I I SC: 098 I Accepted o: --ro � Date: j j —) �- I `-'� � Asci ned To: I I l Rev. 07/16/12 UST RETROFIT VERIFICATION